NPIMap

Organization Active NPI

Covenant Community Care, Inc.

  • Federally Qualified Health Center (FQHC)
  • Detroit, MI
National Provider Identifier
1255574265
Registry record updated Apr 10, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
4704195855 Issued in MI
Legal business name
COVENANT COMMUNITY CARE, INC.
Practice address
1700 Waterman St
Detroit, MI 48209-2022
Phone
(313) 841-1612
Fax
(313) 554-1918
NPI assigned
Apr 7, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 10, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Anna Griebel Chavez
Title
Cfo
Phone
(313) 554-0485

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 4704195855 MI Primary

Addresses

Primary practice location

1700 Waterman St
Detroit, MI 48209-2022

Mailing address

559 W Grand Blvd
Detroit, MI 48216-2200
Phone (313) 554-0485

Other names 1

  • Waterman Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080326000806 MI Part A Provider - Federally Qualified Health Center (FQHC) 1254393549 1 other NPI on this enrollment
Practice locations: Detroit, MI

Federally qualified health center certification: CCN 231928

Legal name
COVENANT COMMUNITY CARE, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 19, 2008
Last certification
May 19, 2008
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Apr 20, 2000 in MI
Enrollment address
1700 Waterman St
Detroit, MI 48209-2022

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Covenant Community Care Inc5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Joslyn Pettway Individual Corporate OfficerCeo Sep 28, 2019
W-2 Managing EmployeeCeo Sep 28, 2019
Mark Lubienski Individual Corporate DirectorBoard Treasurer Feb 1, 2017
Mitzi Cardona Individual Corporate DirectorBoard Vice-Present Aug 8, 2018
Julia Smith Individual Corporate DirectorBoard President May 15, 2018
Catherine a Wenz Individual Corporate DirectorBoard Secretary Aug 1, 2022
Prince Williams Individual Corporate DirectorBoard Member Dec 15, 2020
Semmeal Thomas Individual Corporate DirectorBoard Member May 6, 2013
Samuel Spruill Individual Corporate DirectorBoard Member Mar 6, 2013
Nancyann Turner Individual Corporate DirectorBoard Member Sep 21, 2021
Elizabeth Pitts Individual Corporate DirectorBoard Member Mar 21, 2023
Anna Griebel Chavez Individual Corporate OfficerCfo Jul 11, 2016
W-2 Managing EmployeeCfo Jul 11, 2016
Ester Gallegos Individual Corporate DirectorBoard Member Jul 13, 2021
Graciela Villalobos Individual Corporate DirectorBoard Member Jan 1, 2007

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1239062400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1681084800000",
    "number": "1255574265",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "559 W GRAND BLVD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482162200",
            "telephone_number": "313-554-0485",
            "fax_number": "313-554-3885"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1700 WATERMAN ST",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482092022",
            "telephone_number": "313-841-1612",
            "fax_number": "313-554-1918"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COVENANT COMMUNITY CARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-04-07",
        "last_updated": "2023-04-10",
        "certification_date": "2023-04-10",
        "status": "A",
        "authorized_official_last_name": "CHAVEZ",
        "authorized_official_first_name": "ANNA",
        "authorized_official_middle_name": "GRIEBEL",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "313-554-0485"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MI",
            "license": "4704195855",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Waterman",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Waterman",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Detroit, MI

Sources for this page

Verify at the official NPI Registry.